Hacker News Reader

Comment by crazygringo | Hacker News Reader

> Only around 10 percent of people who saw a doctor at the Mayo Clinic after noticing an abnormal pulse reading on their watch were eventually diagnosed with a cardiac condition... it may take up doctor and patient time unnecessarily.

I... utterly fail to see the problem here.

If it were 0.01% that ended up having a problem, then OK I can see how this is not a signal worth paying attention to. But 10%?! 10% is huge.

Plus, there's no evidence of any harmful side effects here -- it's not like people are being sent into unnecessary surgery because of what their Apple Watch said. They're simply being given normal tests.

Now if Apple can make this more accurate, then great. But if this saves even a few lives, then the fact that 9 out of 10 warnings are false positives still seems extremely worth it, no?

The article paints this as a failure, when all I'm seeing is success.

View on HN

>Now if Apple can make this more accurate, then great. But if this saves even a few lives, then the fact that 9 out of 10 warnings are false positives still seems extremely worth it, no?

No, not by a long shot, because physicians are a pretty rare commodity, care is expensive and sending nine out of ten people to the doctor for no reason is a huge drain on the system and public healthcare resources.

if you see this as success I don't think you're familiar with the concept of opportunity costs. For people who don't have any symptoms, have no history of heart conditions or other underlying risks, running around with an EKG on your wrist is absolutely ridiculous. All it will do is inflate healthcare costs with little improvement in outcome, which is already the primary disease of the US healthcare sector. And of course apple's and the healthcare sectors primary motivation to sell these things to begin with.

Not every cardiac condition even requires immediate attention by a physician, I wager most of the anomalies that show in the 10% are benign arrhythmias that would have been picked up on a yearly routine checkup in due time.

My GP is an “old school” family doctor in a small town. I’ve had similar inquiries in the past, and just scheduled an appointment with his receptionist. She had me describe the concern, his nurse - an NP, I think - approved the tests and the results were discussed at my next scheduled checkup. The actual physician had maybe an added couple of minutes demand on his time to view the results.

I don’t think this is anywhere near enough of an impact in terms of “false positives” to be a net negative.

Nine out of ten people are not being sent to the doctor for no reason. The rest of this comment is catastrophizing.

10% positive predictive value for something like this is pretty good. It’s certainly better than “hey look at this weird mole.”

50% of those 10% positive cases were atrial fibrillation which is pretty serious (can lead to stroke), and wouldn't be diagnosed at a routine checkup as it requires an ECG

https://academic.oup.com/jamia/article/27/9/1359/5911974

> sending nine out of ten people to the doctor

That's not happening. Only a small number of people went to the doctor. Of that number, 9 out of 10 ended up not being diagnosed with a (new) problem, but it seems that even some of them had related problems that were already diagnosed.

Regardless, we don't know the false positive rate. It's not 90%. You need to know the number of negatives before you can calculate it.

I had always been under the impression that the largest fraction of our spending was on people with chronic conditions or serious life-threatening medical issues like cancer? It's hard to imagine that people going to see the doctor once more per five years is really going to move the needle that much on resource consumption.

> >Now if Apple can make this more accurate, then great.

> No, not by a long shot, because... [opportunity costs, overloading the healthcare system]

Totally agree with all of that.

Why don't EKG salons exist (like nail and hair salons)? New market opportunity created by the Apple Watch?

I’m not making any claim about what the Apple Watch detects, or where we are w.r.t. detecting abnormalities in heart rate/rhythm/…, but the better our measurements get, the less serious the average detected abnormality will get.

In this case, all we know is they had they had a “clinically actionable cardiovascular diagnosis”. That action might have saved lives or might have added a few healthy months to the lives of a few, at the cost of requiring 20 to undergo treatment, spend time waiting for treatment, be worried, etc.

There can be a point where the cost and risks of testing people we can’t make healthier (either because they aren’t ill or because they are, but no effective treatment exists) outweighs the gains made by treating people we can treat.

That’s what the article being discussed, IMO rightfully, tries to measure.

Let's take this idea to the extreme for a moment and see if you agree that it's a problem.

A new device is created that alerts 50% of the US population that they have a condition that needs to be treated. Only 10% of those cases warranted further action.

Do you imagine there would be adverse side effects of hospitals being overrun with patients that didn't need to be there?

How can you utterly fail to see a problem with an influx of false positives to an already overloaded healthcare system?

This is ridiculous, if such a device exists and can detect a new condition that 5% of the US population has with a 80% false positive rate, and the condition was as serious as heart disease this would really be a miracle device and people would be grateful that such a thing exists.

I really have distaste for those comments that attempt to mask ideology with a veneer of logic. You attempt to use a limiting case argument that actually proves the original comment's argument and then end with rhetoric about how the healthcare system is being flooded already. That may be true, but that isn't relevant to the utility of the apple watch in this scenario.

> This is ridiculous, if such a device exists and can detect a new condition that 5% of the US population has with a 80% false positive rate, and the condition was as serious as heart disease this would really be a miracle device and people would be grateful that such a thing exists.

Since we're overly simplifying, there _are_ devices that can detect conditions that 5% of the population has _and_ have far fewer false positives - X-rays, CT scans, MRI. In the grand scheme amazing things, but no-one's calling them "miracle devices".

> there _are_ devices that can detect conditions that 5% of the population has _and_ have far fewer false positives - X-rays, CT scans, MRI.

Perhaps, but you can't wear one on your wrist and you generally have to be quite sure something is wrong first.

Oh, but they are miracle devices, and were considered as such initially. But the difference between them and the hypothetical miracle device is accessibility. MRIs and CT scans are not something you can use to casually test half of the country's population.

You might be right in an ideal world, but in reality there are significant resource constraints on healthcare.

What would be more likely to happen in that scenario, is that so many people would be seeking care that the 5% who were positive would be unlikely to even get the care they need.

Further, such an influx would have knock-on effects on unrelated patients, whose care would suffer due to the severe lack of resources.

This is all magnified if the resource is not a general practice physician, but a specialist.

Wait - but if I'm reading the article correctly, it's not the case that all these people are flooding the ER, requiring urgent care. An alert pops up, a person is concerned, they decide to schedule a visit to their doctor.

If the healthcare system - paid healthcare system - can't handle a slow baseline increase in non-emergency visits, then something is seriously wrong with this picture.

That really does sound like ideology cloaked in common sense. Demand for great healthcare is already essentially infinite no matter what new technology comes along, and we need a sane way to deal with that. Pointing fingers at the demand side is a common diversionary tactic.

> Further, such an influx would have knock-on effects on unrelated patients, whose care would suffer due to the severe lack of resources.

Hypothetically, let's assume over a long period of time new devices are alerting users to possible medical conditions. Those appointments are paid for (I'm guessing). Will that money not fund more availability over time? The supply of doctors is not supposed to be fixed.

The study started with 767,338 patients with clinical notes.

Out of that haystack, only 41 referred to an Apple Watch alert about abnormal pulse detection.

And of that 7 were found to have enough concern to further explore potential cardiovascular disease.

So, out of three quarters of a million visits, there were 41 with concerns from an Apple Watch, and 7 people received early treatment they might not have otherwise received (which could potentially save millions of dollars of future healthcare costs).

34 people were false positives and inconvenienced with a doctor's visit.

This seems like a net positive.

Since you're feeling judgmental ("How can you utterly fail to see a problem..."), let's take it the other extreme.

Suppose a device is released that has a 30% false positive rate: two-thirds of the people it identifies have an actual underlying condition that requires treatment.

Presumably you would not be opposed to this. (If you do, you'd seem to be opposed to any effort to catch conditions early.)

So then we're at a discussion about what the correct percentage of false positives is for a further diagnostic - in this case, likely a holter monitor, to identify if it's an actual issue, which is not that expensive.

You believe it's obvious that ten percent is an outrageous number. But if the next step is a fairly inexpensive diagnostic, and the subject matter is a potentially lethal condition (often the case with hearts), it's not obvious at all.

What's your acceptable "brightline" of maximum false positivity to warrant additional diagnostic? Fifty percent? Twenty percent?

I'm going to risk going against the zeitgeist and expose myself to a bunch of downvotes right now.

But what you described sounds reminiscent of the PCR test we have for COVID right now. I at least hope many are aware of this here.

> I'm going to risk going against the zeitgeist and expose myself to a bunch of downvotes right now.

It’s off topic, but I recommend you do it. I’ve found HN to be a great place for those types of discussions provided you have a relatively thick skin and don’t engage in hostility.

> A new device is created that alerts 50% of the US population that they have a condition that needs to be treated. Only 10% of those cases warranted further action.

This just improved the lives of 16 million people. That is not insignificant. And that's assuming 16 million people would have the same condition.

This also might be underestimating the number of false positives doctors already deal with and that these devices may actually lower that number.

That's an unrealistic scenario since 5% (10% of 50%) of the population doesn't have an otherwise difficult to detect and life threatening condition. And if they did, then there is a serious problem and we would expect the hospitals to be overrun.

We also don't know the doctors' false negitive rate.

Reply on news.ycombinator.com